Cal. Code Regs. tit. 8 § 9789.12.11

Current through Register 2024 Notice Reg. No. 44, November 1, 2024

Section 9789.12.11 - Evaluation and Management: Coding - New Patient; Established Patient; Documentation

(a) For purposes of workers' compensation billing, the following definitions of "new patient" and "established patient" will be used instead of the CPT definitions:

(1) A "new patient" is one who is new to the physician or medical group or an established patient with a new industrial injury or illness. Only one new patient visit is reimbursable to a single physician or medical group per specialty for evaluation of the same patient relating to the same incident, injury or illness.

(2) An "established patient" is a patient who has been seen previously for the same industrial injury or illness by the physician or medical group.

(b) This subdivision is applicable to services rendered prior to March 1, 2021. To properly document and determine the appropriate level of evaluation and management service, physicians and qualified non-physician practitioners must use either one of the following guidelines but not a combination of the two guidelines for a patient encounter. If the physician's or qualified non-physician practitioner's documentation for a medically necessary service conforms to either one of the guidelines, the maximum reasonable fee shall be according to the documented level of service:

(1) The "1995 Documentation Guidelines for Evaluation & Management Services," or

(2) The "1997 Documentation Guidelines for Evaluation and Management Services."

Both guidelines are incorporated by reference and are available on Medicare's website, or will be made available upon request to the Administrative Director.

The 1995 version is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf

The 1997 version is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

(c) For services rendered on or after March 1, 2021, the selection of the level of office/outpatient visit evaluation and management service code is governed by the CPT coding and guidelines, except as otherwise provided in the regulations.

(1) When the practitioner selects a visit level using time, the practitioner may report prolonged office/outpatient Evaluation and Management visit time using HCPCS add-on code G2212 (Prolonged office/outpatient E/M services). Do not report prolonged office/outpatient Evaluation and Management visit time using CPT code 99417.

(2) For services on or after March 1, 2021 and prior to February 15, 2023, HCPCS code G2212 is defined as follows:

Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services). (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes).

(3) For services on or after February 15, 2023, HCPCS code G2212 is defined as follows:

Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215, 99483 for office or other outpatient evaluation and management services) (do not report G2212 on the same date of service as 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes).

Cal. Code Regs. Tit. 8, § 9789.12.11

Note: Authority cited: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g)(Register 2013, No. 39).
2. Amendment of section heading and subsection (b) and new subsections (c)-(c)(3) filed 6/10/2024: operative 4-15-2024. Submitted to OAL as a file and print only pursuant to Labor Code section 5307.1(g)(2) (Register 2024, No. 24).